Anthem Blue Cross Avondale Represented EPO

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Annual prescription deductible Annual Rx out-of-pocket maximum Retail generic Retail formulary brand Retail nonformulary brand Mail order generic Mail order formulary brand Mail order nonformulary brand Oral contraceptives Fertility drugs Injectables Coverage Adult Preventive Care Annual physical exam Well-woman exam (includes pap) $250 Individual; $500 Family; two family members must meet the individual deductible before family deductible is satisfied $0 Individual; $0 Family 90% covered; 30 day supply 80% covered; 30 day supply 80% covered; 30 day supply 90% covered; 90 day supply 80% covered; 90 day supply 80% covered; 90 day supply Retail and mail order available Not covered Applicable medical or prescription drug coinsurance or copays apply; check with Anthem or Express Scripts for details Anthem Avondale Rep EPO Not covered $15 copay; limited to two routine gynecological exams and Pap tests per benefit plan year; no limit for medically necessary services Mammogram 100% covered; for members after age 35; maximum benefit of $150 Colonoscopy 100% covered; limited to one per benefit plan year after age 50 Cancer screenings Applicable copays apply; prostate exams limited to one screening after age 50 Cardiovascular screenings Not covered Allergy tests and treatments 100% covered after office visit copay Family Planning Fertility services Not covered In vitro fertilization Not covered Artificial insemination Not covered Female tubal ligation Applicable copays apply Male vasectomy Applicable copays apply Maternity Care Office visit: Pre/postnatal $15 copay In-hospital delivery services 100% covered; preauthorization required Newborn nursery services 100% covered; preauthorization required Well-Baby/Well-Child Preventive Care Pediatric exams Immunizations (child) Mental Health Care Not covered; applicable copays apply for newborn nursery charges and circumcision only Not covered
Mental Health: Combined with substance abuse Yes; outpatient only Mental Health: Outpatient coverage Mental Health: Inpatient coverage Behavioral health member services Behavioral health vendor Behavioral health Web site Substance Abuse Care Detox: Outpatient coverage Detox: Inpatient coverage Rehab: Outpatient coverage Rehab: Inpatient coverage Dental Dental implants Accidental injury to teeth Surgical removal of tumors, cysts, and impacted teeth Vision Care Routine vision exams Regular lenses and frames Contact lenses Hearing Care Hearing evaluations Hearing aids Medical Therapy Acupuncture Chiropractic Outpatient physical therapy Outpatient speech therapy Outpatient occupational therapy Care at Alternate Sites Noncustodial home health care Prescribed care in noncustodial skilled nursing facility Hospice care Other Services 80% covered; limited to 24 hour crisis intervention and evaluation/outpatient counseling; limited to 50 visits per year 100% covered; limited to 30 days per year Same as medical plan Same as medical plan Same as medical plan 80% covered; limited to 24 hour crisis intervention and evaluation/outpatient counseling; limited to 50 visits per year 100% covered; limited to 2 episodes per lifetime; dependents not covered 80% covered; limited to 24 hour crisis intervention and evaluation/outpatient counseling; limited to 50 visits per year Not covered Not covered $15 copay Applicable copays apply; limited to surgical removal of tumors and cysts; removal of impacted teeth not covered Not covered Not covered Not covered Not covered Not covered Not covered 50% covered; limited to $500 per benefit plan year; including x-rays $15 copay; limited to 60 visits per benefit plan year $15 copay; limited to 60 visits per benefit plan year $15 copay; limited to 60 visits per benefit plan year 100% covered; limited to 30 days; preauthorization required 100% covered; limited to 50 days; preauthorization required 100% covered
Page 1: Huntington Ingalls Industries, Inc.
Page 5: The comparison charts are compiled

Anthem Blue Cross Avondale Represented EPO

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